Dr. Joseph Hecht with hopefully his very last Mark Prior update ever...
UPDATE: Will Carroll stopped by in the comments to clear up a few matters and there's a follow-up by our doctor.
I know, we’re all tired of reading about Mark Prior’s injuries. Now that we have diagnoses that match his symptoms, hopefully we can just move on. Cubs.com site
says that Mark Prior’s surgeon, Dr. Andrews, did a debridement of Prior's right rotator cuff, as well as repair the labral and capsular injuries in his right shoulder. Sounds accurate enough to me.
Will Carroll has an unfiltered update
on Mark Prior if you have a Baseball Prospectus subscription. I wanted to try sort through the terminology and implications.
: "Sources indicate the surgery was done completely with the scope and involved a Bankart repair and capsular shift. The Bankart repair involves... anchoring the capsular ligaments and glenoid labrum into anchors drilled into the scapula. Despite all this, it can be done completely arthroscopically.”
: A Bankart lesion
repair refers to fixing a detachment of the labrum AND capsule, including the main (glenohumeral) ligaments, and reattaching them back to the front of the shoulder socket (glenoid rim). This is a bigger tear than a labral tear
, which is just the fibrocartilage rim on the socket. In the last few years implants (anchors
) have been developed which can reattach this tissue with arthroscopic techniques. These Bankart lesions occur with shoulder dislocations or at least partial dislocations termed subluxations. If Mark Prior did have a Bankart lesion, I would presume it occurred when he was injured in the Marcus Giles collision back in 2003 (instead of what was reported, which was an AC joint sprain).
Did #22 tear the front of his shoulder and have a partial shoulder dislocation with that fateful basepath collison
? Could he still pitch effectively with this after the injury? Yes, at least for a while.
Historically, dislocations were not operated on until recurring or chronic instability occurred which can develop over years. So the rehab he was getting would have been the traditional approach here. Newer arthroscopic techniques may be changing this approach. These tears in high profile athletes are getting fixed more often upon the initial injury because they can be done less invasively.
A Bankart repair can address capsular laxity as well (see below regarding the capsular shift procedure).
Will Carroll says
: “The cuff debridement is the most significant injury.”
: This is unlikely to be more problematic than the need for a Bankart type repair of the anterior capsule unless it was a full thickness cuff tear (which wasn't reported).
Impingement or friction on the cuff can also be related to the shoulder instability, so any cuff wear can be secondary to the anterior capsular tear. Like a loose door hinge that causes the door to get scuff marks when it closes. Bursal sided Rotator Cuff debridement is usually accompanied by shaving the overlying acromion
, which opens the space where the impingement occurs. I haven't seen any reporting of this as yet.
Will Carroll’s speculates
on the capsular surgery:
“The capsule repair probably involved a capsular shift. In this the surgeon will make a "small incision" in the front of the shoulder, then folds an overlap to shrink the capsules circumference. It’s like folding over one of those funny pictures on the back of Mad Magazine.”
: if the procedure was all arthroscopic (also reported on the cubs.com site), then a capsular shift wasn't done, since this is an open procedure and is done for loose capsules when the labrum and front of the shoulder capsule is intact and firmly anchored. What can be done with the scope in a lax capsule situation is a capsular shrinkage
with a thermal probe. This basically burns the capsule at several locations causing it to shrink, thus tightening it.
It is possible MP had a capsular shift through a small incision, if the labrum wasn't detached but just needed shaving, but then using the term Bankart repair would be incorrect. An open capsular shift is usually not done in conjunction with a Bankart type repair as it would tighten up the shoulder in two places making it hard to tell how much is too much, particularly for a pro pitcher, as the Bankart repair can alone be used to tighten up the capsule significantly just by where the capsule tissue grasped when it is re-anchored down to the socket.
The weblinks Will Carroll used in his Prior update had some odd choices and they made me realize most of the media writers don’t have a solid handle on the medical details. This link from "small incision"
which goes to a web page with a large shoulder incision used in shoulder replacement with a metal rod in the humeral head (used as an alignment guide). Don’t look if you can’t stomach fillet of shoulder. We’re not supposed to say "oop"s in surgery. Given his Mad Magazine fold-in
reference regarding capsular shift, I’ll go with "What Me Worry" instead of "Oops". Hopefully, Will doesn’t do his own links.
Will Carroll’s wrap up
..."So what does this mean? First, it means that Prior had been pitching with significant damage for the past two years."
Prior, at 26 years old, now has the rest of 2006 to rehab and still could have a career ahead of him. Without pain, one would assume that he could return to those same mechanics that allowed him to become the pitcher he once was. There’s a small silver lining here in a dark black cloud over Wrigley."
My comment and questions
: Something doesn’t mesh here. Why did one of the most highly regarded baseball pitchers since starring in college have to go through several wasted seasons without knowing what was wrong? Now we have a diagnosis, well actually three diagnoses. It seems like the saddest part of the problem was that it took much too long to finally get to this point. Why does this only happen to the Cubs?